Provider First Line Business Practice Location Address:
224 4TH ST NW
Provider Second Line Business Practice Location Address:
SUITE 5
Provider Business Practice Location Address City Name:
DEVILS LAKE
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58301-2960
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-662-6776
Provider Business Practice Location Address Fax Number:
701-662-6889
Provider Enumeration Date:
11/16/2006